Change in Dismissal

Please fill out the form to notify school of a change of transportation for your child. This form must be submitted before 2pm (or 12Pm on Early Release days) on the day of the dismissal change, in order to be processed.

Date Date / MM / DD YYYY
Student Name Student Name First Last
Student Number
Grade Level

Grade Level VPK Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade
If the student is in middle school, are they already aware of the change?

If the student is in middle school, are they already aware of the change? Yes No N/A
Teacher Name
Parent/Guardian Name Parent/Guardian Name First Last
Please provide a phone number in case we need to contact you. Please provide a phone number in case we need to contact you. - ### - ### ####
Parent/Guardian Email
Typical Mode of Transportation

Typical Mode of Transportation Bus rider Car rider PLACE Walker/biker Daycare Van
Change my child's transportation to

Change my child's transportation to Bus rider Car rider PLACE Walker/biker Daycare Van
If you are changing your mode of transportation to a daycare van, please indicate the daycare van your child will be riding.
This is a permanent change. My child will be using this dismissal route everyday

This is a permanent change. My child will be using this dismissal route everyday Yes No, today only
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Spam Protection. Please answer this simple question:
What is the sum of 2 and 2 ?